Evolve HESI Medical Surgical Practice Exam

Questions 45

HESI RN

HESI RN Test Bank

Evolve HESI Medical Surgical Practice Exam Questions

Question 1 of 5

The nurse is caring for a patient whose serum sodium level is 140 mEq/L and serum potassium level is 5.4 mEq/L. The nurse will contact the patient's provider to discuss an order for

Correct Answer: A

Rationale: In the scenario presented, the patient is experiencing mild hyperkalemia with a potassium level of 5.4 mEq/L. The appropriate intervention for mild hyperkalemia is a low-potassium diet to restrict potassium intake. This helps in managing and preventing further elevation of potassium levels. Intravenous sodium bicarbonate is not indicated as the patient's sodium level is normal at 140 mEq/L. Kayexalate, a cation-exchange resin, is typically used for severe hyperkalemia to promote potassium excretion. Salt substitutes, which often contain potassium chloride, should be avoided in patients with hyperkalemia as they can exacerbate the condition by increasing potassium levels further.

Question 2 of 5

After an endotracheal tube is placed in a client who experienced sudden onset of respiratory distress, what should the nurse do?

Correct Answer: D

Rationale: After endotracheal tube insertion, the nurse should auscultate both lungs for the presence of breath sounds. This step helps confirm proper tube placement and adequate ventilation. Auscultation of breath sounds is crucial to ensure that the tube is correctly positioned in the trachea and not in the esophagus. While securing the tube with tape is important, it is not the immediate priority after insertion. Ordering a chest x-ray may be necessary but is not the first action to take immediately post-intubation. Documenting the depth of tube insertion is important but ensuring proper ventilation through auscultation takes precedence.

Question 3 of 5

A patient has been taking spironolactone (Aldactone) to treat heart failure. The nurse will monitor for

Correct Answer: A

Rationale: The correct answer is A: hyperkalemia. Spironolactone is a potassium-sparing diuretic commonly used in heart failure management. One of the major side effects of spironolactone is hyperkalemia, which is an elevated level of potassium in the blood. Monitoring for hyperkalemia is crucial as it can lead to serious cardiac arrhythmias. Choices B, C, and D are incorrect. Hypermagnesemia (choice B) is not typically associated with spironolactone use. Hypocalcemia (choice C) and hypoglycemia (choice D) are also not directly linked to the use of spironolactone in heart failure treatment.

Question 4 of 5

A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, the nurse should first assess:

Correct Answer: D

Rationale: The client's dyspnea is most likely related to an air leak caused by a loose connection in the chest tube system. Checking the chest tube connections should be the initial action because correcting an air leak can quickly resolve the client's symptoms. If a leak is found and corrected, the dyspnea should improve. Assessing the client's vital signs (Option A) is important, but addressing the potential cause of dyspnea takes precedence. Monitoring the amount of drainage (Option B) is necessary for assessing the client's overall condition, but in this case, the dyspnea is likely due to an air leak. Checking the client's lung sounds (Option C) is essential for respiratory assessment, but addressing the air leak should be the immediate priority to ensure adequate lung expansion and oxygenation.

Question 5 of 5

Upon arrival of a client transferred to the surgical unit, what should the nurse plan to do first?

Correct Answer: A

Rationale: The initial action for the nurse upon the arrival of a client to the surgical unit is to assess the patency of the airway. This step takes priority to ensure that the client has a clear airway for adequate breathing. Checking tubes and drains for patency, inspecting the dressing for bleeding, and assessing vital signs to compare with preoperative measurements are important subsequent steps in the assessment process. However, ensuring the airway is patent is the immediate priority to maintain the client's respiratory function and overall well-being.

Similar Questions

Join Our Community Today!

Join Over 10,000+ nursing students using Nurselytic. Access Comprehensive study Guides curriculum for HESI-RN and 3000+ practice questions to help you pass your HESI-RN exam.

Call to Action Image